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Report on Fellowship at National Cancer Centre, Tokyo

Dr Paulose George

November 2012

Background:

I was granted a fellowship in May 2012 by the BSG and WAGE to visit the National Cancer Centre in Tokyo. As the lead Gastroenterologist for the Cross Border Upper GI Cancer Centre based at Wrexham and accredited screening colonoscopist I have been doing endoscopic resection of early GI cancers since 2008. Endoscopic resections of early cancers offer a cure without the morbidity and mortality that is often associated with major surgery. Endoscopic treatment of GI cancers was pioneered by the Japanese and is now gaining popularity world wide. This technique started as endoscopic mucosal resection (EMR) but gradually evolved into endoscopic submucosal dissection (ESD) allowing en bloc resection of large lesions and histological confirmation of a curative resection. The advanced diagnostic endoscopy practised in Japan improves detection of early cancers of GI tract and prediction of depth of invasion of these early lesions based on pit pattern and capillary vascular pattern.

Fellowship:

Institution – Endoscopy Division, National Cancer Centre Hospital, Tokyo

Period – 19 Nov – 30 Nov 2012

Mentor - Dr. Takahisa Matsuda

I spent the normal working hours Monday to Friday in the busy endoscopy unit with 7 rooms undertaking on an average 20 colonoscopies and 50 upper GI endoscopies per day. Their routine work included advanced diagnostic techniques to detect early cancers and a range of therapeutic work such as complex EMR, ESD and EUS guided FNA, offering good case mix and excellent learning environment.

During my tenure there I attended multidisciplinary meetings and clinicopathological conferences which are usually held early morning or late evening outside normal working hours. Few of the meetings were in English and it helped me to understand their approach to diagnosis and management of GI cancers.

There are eight consultants in the endoscopy unit with varying sub speciality interests and they were all very eager to discuss and share their experience with us. Experts from around the world visit NCC regularly and the opportunity to interact with them was an added bonus.

They had set up an animal model and this helped me to improve my skills by going through the various steps meticulously under the supervision of experts. As part of the continuing professional development I used the break to do literature search relevant to endoscopic diagnosis and treatment of cancers. I also helped Dr. T Matsuda by reviewing the manuscript for two of his papers due to be published soon.

My hosts were very kind and considerate. We enjoyed Japanese hospitality and the nice banquet they hosted to honour us.

Take home message:

  • definitely improved my practical skills and knowledge in the areas of ESD, chromoendoscopy and principles of assessing depth of invasion based on endoscopic morphology.
  • Japan has the highest 5 year survival for GI cancers in the world in spite of very high prevalence.
  • 50 % of all the GI cancers diagnosed in Japan is localised (T1) resulting in excellent five year survival.
  • The per capita healthcare spending in Japan is almost same as UK but the average life span in Japan is one of the highest in the world.
  • Japanese endoscopists are highly skilled in detecting early lesions and their meticulous and systematic approach is worth noting.
  • They use same day bowel cleansing using PEG as day case in hospital just before the colonoscopy. The nurse checks the quality of bowel preparation before the patient is allowed into the procedure room and this helps to maintain very high standards.
  • The service is organised efficiently with very little downtime resulting in high throughput of cases without compromising quality. The local service is shaped by the front line clinical staff and there was no bureaucracy at the front end.
  • Japanese treat endoscopy more as a fine art than a mere skill, Endoscopy training is more hands on and trainees learn by apprenticeship.
  • Patient care is individualised based on the clinical needs rather than blindly adhering strictly to guidelines and protocols creating an atmosphere for continuous innovation and improvement of care.

Future plan:

Personal:

  • Improve the outcome of ESD service locally and introduce the concept of detection of early cancers in Barrett's oesophagus and the colon.

Local:

  • Establish collaboration between NCC and Cross border Upper GI cancer centre to facilitate research, exchange of ideas and sharing of good practice.
  • It will be useful for other members of the Cancer MDT – surgeons, pathologist and oncologist – to visit NCC to learn from their good practice.

National:

  • Improve the detection rate of early malignant lesions in the GI tract in the UK by sharing the lessons learnt through continuous professional development.
  • BSG should set up a joint working party with Japanese endoscopists to promote detection and roll out of endoscopic treatment for early cancers of the GI tract in the UK which in turn will have the biggest positive impact on cancer survival – a suggestion made by Dr. Takuji Gotoda during my visit in 2008.

Acknowledgment:

I am grateful to the BSG and WAGE for giving me this valuable opportunity to enhance my knowledge and skills in the field of detection and treatment of early cancers of the GI tract

Dr. T Paulose George MD, Dip NB, FRCP

5th December 2012